Applications of robot assisted surgery in gynecology Jan Persson Lund University hospital Sweden Jan Persson April 2009
Robotiv surgery = laparoscopic surgery with a sophisticated tool Most applications are scientifically well established concerning safety and oncological outcome ( trad. laparoscopy) Advanced traditional laparoscopy has not been generally implemented Robot VS traditional laparoscopy remains controversial Economic data comparing robot with traditional laparoscopy and laparotomy are missing
A+B= Da Vinci standard A C B+C= Da Vinci S C+D= Da Vinci SI D B
The robotic phases 1 The initial enthusiasm
The robotic phases 2 Frustration
The robotic phases Radical hysterectomy + RH nerve sparing 08:38 07:40 06:43 Hours 05:45 Surgeon A Surgeon B 04:48 Surgeon C 03:50 02:52 01:55 00:57 00:00 0 2 4 6 8 10 Procedure number 3 Learning phase 12 14
The robotic phases 4 Confident innovative phase
Requirements for a successful robotic programme >=350 procedures / year/ robot >= 50 procedures /doctor/ year. >=100-200 procedures/speciality-team/year surgical time ( skin-to-skin) for robot ass radical hysterectomy and pelvic LND Dedicated team 2-4 doctors 08:00 3-4 OR nurses + 3-4 circ nurses 06:00 07:00 Surgeon A Surgeon B 05:00 Dedicated anesthesia teams Surgeon C 04:00 Surgeon D 03:00 02:00 01:00 00:00 0 10 20 30 40 50
History of laparoscopic surgery in Lund 1992 First videolaparoscopy equipment 1994 Burch, LAVH 1995 LASH 1996 Total laparoscopic hyst 1996 Vaginosacropexia 2000 Pelvic lymphadenectomia 2002 Paraaortic lymphadenectomia 2005 Radical hysterectomy October 2005 robotassisted laparoscopy April 2007 robot nr 2
Prospective protocol all robot patients Clinical data Surgical / perioperative/ Postoperative 2 months Postoperative one year + Personal identification number /computerized patients files Scheduled flollow up 5 years / clinical Protocol Jan Persson MD PhD Department of Obstetrics and Gynecology University Hospital of Lund Sweden
250 Robotic procedures for malignancies Radical hys terectom y +/- adnex +/nerves paring Onc.s im ple hys t +/- adnex pelvic LND +/- SN 200 Paraaortic LND Res ection of om entum 150 Trans pos ition of ovaries Abdom inal cerclage Rem oval of bulky nodes pre rad 100 Vaginal cuff recurrence cx/param etrectom y 50 Rem oval pelvic s idewall tum or pre rad trachelectom y / fertility s paring 0 radical rem oval of lym phocys t interval s urgery/ ovarian ca Jan Persson April 09
Robotic procedures for selected benign disorders 40 35 30 25 20 15 Simple hysterectomy +/adnex Enucleation of myomas vaginal cuff endometriosis/ endometriomas Abdominal cervical cerclage Suture of post cesarean dehiscense hemihysterectomy/ malformation Scar pregnancy 10 cystoma during pregnancy 5 vaginosacropexia 0 adhesolysis frozen pelvis Jan Persson April 09
Cervical cancer Case load 50 /year Endometrial cancer With new treatment programme estimated case load 100/year Ovarian cancer Case load 20-30 per year.
Robotic radical hysterectomies First 131 cases Cervical cancer Conversions =4 2 Anesth problems 1 Omental met 1 system error Endom. cancer 1a2 1b1 2a 2a-b n = 16 n = 76 n=9 n = 25 *Aborted due to pos SN = 0 *Aborted due to pos SN = 10 *Aborted due to pos SN = 1 Postop chemorad *Postop chemorad *Postop chemorad *Postop chemorad) = 17 =0 =26 =7 Jan Persson March 09 Sarcoma n=1
surgical time ( skin-to-skin) for robot ass radical hysterectomy and pelvic LND 08:00 07:00 Surgeon A 06:00 Surgeon B 05:00 Surgeon C 04:00 Surgeon D 03:00 02:00 01:00 00:00 0 10 20 30 Last 20 procedures: Median time 162 minutes (range 132-232 minutes) Jan Persson April 09 40 50
Robot assisted radical hysterectomy+pelvic LND Postoperative and follow up data 111 women with >=1 month follow up 39 Minor/ moderate adverse events 61 uneventful 11 Re-admissions Hernia (2) Vaginal cuff dehiscensce (5) Hematoma (2) Ureter stricture (1) Chylusscites (1) Jan Persson April 09 Vaginal cuff Infection Lymfoedema Abd wall other
Lymphatic adverse effects after robot assisted radical hysterectomy and pelvic LND 17/111 proximal lymphoedema 8/111 lymphocele 1/111 chylusascites 6/50 distal lympoedema (postop radiotherapy) 2/61 distal lymphoedema (no radiotherapy)
Chylusascites following Robot assisted radical hysterectomy and pelvic LND 65 yo stage 1B1 sq. ep cervical cancer Surgery january 2009 Radical surgery, 44 negative pelvic nodes No postop adjuvant treatment Gradually developed chylus ascites Benign cytology Normal CT abd/ thorax Normal HB, WBC/ diff, Trc Resolved by treament with Sandostatin and fatreduced / MCT diet
Abdominal wall adverse effects after robot assisted radical hysterectomy and pelvic LND 4/111 port site hernia (3 reop) 1/111 muscle rupture 3/111 hematoma 1/111 port site metastase
Lymphatic mapping during robot assisted surgery for cervical cancer Four point submucosal injection of 120 MBc radiotracer (~3 pm) One hour lymphoscintigram Surgery as first case the following morning Laparoscopic gamma-probe SN for frozen section Full pelvic LND Jan Persson April 09
Trachelectomy: Fertility-Sparing in Cervical Cancer Jan Persson MD PhD Director of minimally invasive and robotic surgery Department of Obstetrics and Gynecology University Hospital of Lund Sweden Jan Persson April 09
Trachelectomy: Fertility-Sparing in Cervical Cancer The pioneer in memoriam! Jan Persson April 09
Radical trachelectomy 900 cases published (Shepherd 2008) 760 of the cases are vaginal trachelectomy with laparoscopic pelvic LND (Shepherd 2008) 43% attempt pregnancy; 70% pregnancy rate (Ramirez 2008) >45% of women <40yo with operable cancer theoretically suitable for fertility sparing surgery (Sonoda 2008) Jan Persson April 09
Robotic trachelectomies, publications Published Cases n Tumor stage Op time Bleeding ml Uterine Artery Cerclage Persson et al. 2 1b1 1A2 387 358 100 / 150 spared yes Geisler et al. 1 1B1 Adenosarc 172 100 sacrificed yes Chuang et al. 1 1A2 345 200 sacrificed yes Persson J, Kannisto P, Bossmar T. Robot-assisted abdominal laparoscopic radical trachelectomy. Gynecol Oncol. 2008 Dec;111(3):564-7. Epub 2008 Jul 11. Geisler JP, Orr CJ, Manahan KJ.Robotically assisted total laparoscopic radical trachelectomy for fertility sparing in stage IB1 adenosarcoma of the cervix. Laparoendosc Adv Surg Tech A. 2008 Oct;18(5):727-9. Chuang LT, Lerner DL, Liu CS, Nezhat FR. Fertility-sparing robotic-assisted radical trachelectomy and bilateral pelvic lymphadenectomy in early-stage cervical cancer. J Minim Invasive Gynecol. 2008 Nov-Dec;15(6):767-70.
Position of cervical cerclage and length of the remaining cervix 11 mm cerclage Jan Persson MD PhD Department of Ob&G University Hospital of Lund Sweden
Trachelectomy Pros and cons, personal view Vaginal trachelectomy Robotic trachelectomy Documentation +++ 0 (+) Adoption of technique +/- ++ Tailoring of parametrial dissection + +++ Allowing nervesparing dissection - +++ Conversion to Radical hysterectomy + +++ Surgical time ++ -? Control of cervical transsection point ++ +++ Placement of cerclage / risk of rejection / erosion - ++? Jan Persson April 09
Recent aims Further reduction of set up and turnover times Further reduction of consol time 3 operations / day Minimize number and size of ports Minimize number of instruments Further improve perioperative care Increase research activity Side docking
Publications on robot assisted surgery. Persson J, Kannisto P, Bossmar T. Robot-assisted abdominal laparoscopic Vesselsparing radical trchelectomy. Gynecol Oncol 2008, Dec;111(3):564-7. Persson J, Reynisson P, Borgfeldt C, Kannisto P, Lindahl B, Bossmar T. Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data. Gynecol Oncol 2009 May, 113(2):185-90. Persson J, Gunnarsson G, Lindahl B. Robot assisted surgery of a 12-week scar pregnancy with temporary occlusion of the uterine bloód supply. J Rob Surg 2009;3:53-55 Lonnerfors C, Persson J. Robot assisted laparoscopic myomectomy for unfavourably situated myomas. Acta Obst et Gyn Scand, 2009;88:994-99 Anderberg M, Bossmar T, Arnbjornson E, Isaksson J, Persson J. Robot assisted hemihysterectomy for a rare genitourinary malformation with associated vessel anomalies. Case report. J Ped surg, in press Lonnerfors C, Persson J. Applications of robot assisted surgery in a mixed gynecological and gyneoncological unit. In abstract Persson J April 09
Studyvisits and/or proctorings Planned visits
www.sergs2009.org
2:nd European Symposium on Robotic Gynaecological surgery September 2010 Lund Sweden www.sergs2010.org
www.practicum.se Practicum Robotic School Lund University hospital In collaboration with Intuitive surgical Training robot Porcine model Team training/ preparation/ set up case observations on demand
Thank You for Your attention Dr Jan Persson Dr Päivi Kannisto Dr Christer Borgfeldt Dr Thomas Bossmar Dr Bengt Lindahl Dr Celine Lönnerfors Dr Petur Reynisson RN Christina Eten-Bergquist RN Anna Fielitz-Axelsson jan.persson@med.lu.se